INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30 - 31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Community Guidance Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed a written policy and procedure manual for 2018 based on a review of the facility's policy manual on July 30, 2019.
The policy and procedure manual was last signed off by the project director on July 31, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- During the year of 2018, the Community Guidance Center experienced a shift in management including a change in the Project Director. Due to the shift in management, a breakdown of processes occurred causing the D&A policy and procedure manual to not be reviewed, updated, and signed. Before this year and for the current year, the Center has been in compliance with this requirement.
To prevent a breakdown of future processes, the D&A policy and procedure manual will be maintained and stored with the overall Center policy and procedure manual to allow for its annual review by the Board of Directors, CEO, and Project Director in the Fall of every year as is the current agency process. To reduce human error and ensure compliance, the Center's internal Relias training/ tracking system will be utilized to ensure the completion of this task.
Effective 10/1/19, the Relias tracking system will be updated to send an automated email reminder to the Project Director and Facility Director directing them to ensure the review, update, and signature of the policy manual for that year. Once the task has been completed, both the Project and Facility Director will enter the date of completion into the Relias tracking system marking the task as completed. The Project and Facility Director will receive automated messages via email of the task due date annually moving forward. They will begin receiving the messages 3 months before due date (July 1) to allow time to have the manual reviewed and signed by all required before the due date of October 1. The automated messages will continue to be sent until the task is completed. The automated messages and compliance with 709.23 will be overseen by the Project Director, Facility Director, and HR specialist responsible for the maintenance of the Relias system.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to document a client rights policy that included all of the client rights based on a review of the facility's policy and procedure manual on July 30, 2019.
The facility's client rights policy did not include the following: "the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines the information may be detrimental if presented to the client and reasons for removing sections shall be documented in the record".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with the corrective action plan, the Informed Consent policy will be established to include all D&A rights and responsibilities. The updated Informed Consent policy with the inclusion of the D&A rights and responsibilities will be completed and implemented as policy by 10/1/19. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document an individual treatment plan that included the frequency of treatment and rehabilitation services in three of seven client records reviewed on July 30 - 31, 2019.
The treatment plan for the following clients indicated they would receive individual counseling but the frequency of these services was not documented.
Client # 2 was admitted December 12, 2018 and discharged February 22, 2019. The individual treatment plan was documented December 27, 2018.
Client # 6 was admitted January 14, 2019. The individual treatment plan was documented January 24, 2019.
Client # 7 was admitted March 1, 2019 and discharged May 20, 2019. The individual treatment plan was documented March 20, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The D&A Training Manual was updated after licensing. The updated manual provides an overview of the D&A Treatment Plan. To enhance training, a step by step completion guide was created to supplement the manual. The step-by-step guide provides direction on completing all aspects of the treatment plan and treatment plan updates to include the documentation of the frequency of service provision. The manual and step-by-step guide will be utilized during the orientation of all new staff effective immediately to ensure understanding before the new staff engage in the completion of service provision. The orientation and training of new staff will be provided by the Department Director.
The tools will also be utilized to train current staff during weekly department meeting throughout the month of August/September 2019 by the Department Director as documented in the meeting agendas. The Director will review and sign off on all treatment plans ensuring the required information is present. The Director will also engage in audits of treatment plans for the next 2 months to ensure the training tools and implementation was effective.
Should there be no ongoing concerns after implementation of training tools, training sessions and audits, the Director will continue to review each service at time of completion and will audit routinely throughout the year. Should there remain ongoing concerns, additional trainings and training tools will be utilized in department meetings and individual supervisions followed by audits until the resolution is the completion of effective treatment plans across the Center. The Department Director will be responsible for the overview of the citation correction with additional oversight from the Project Director.
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